A 44 y/o man being seen today by his primary care provider in clinic for follow up of his hypertension and recent diagnosis of basal cell skin carcinoma on the side of his nose. He underwent Mohs Surgery 6 weeks ago with clean surgical margins. Today, he shares that he is having nightmares, with recurrent themes of death. He has been taking Lisinopril and metoprolol for hypertension for more than 3 years, with no problems; the nightmares started only after his skin cancer was diagnosed.

Although anxiety related to the cancer diagnosis would seem an obvious cause of subsequent nightmares, which one of the following should be assessed as another common cause of nightmares:

a. CT or MRI to rule-out brain metastases
b. current/recent alcohol intake history
c. past history of depression requiring medication
d. serum calcium level

Answer: b.

Nightmares can result from many causes including psychiatric illness, organic brain disease, hypoglycemia, alcohol/drug intoxication and withdrawal. Treatment of nightmares is usually multi-modal including assessment and intervention for psychiatric issues, assessment and intervention for drug/alcohol related problems and assessment/adjustment of prescribed medication. In some patients, specific medication can be added to help reduce nightmares such as benzodiazepines or atypical anti-psychotics. In this patient, brain metastases or hypercalcemia are extremely unlikely. While a past history of depression is always important, an immediate and very common cause of nightmares that can be quickly evaluated relates to alcohol use.

Malhotra S, Arnold R, Patterson, K. Fast Facts and Concepts #88. Nightmares.